The Case For And Problems With The Inclusion Of Gender Dysphoria In The DSM

[Edit: The Trans Bill 2019 states that transgender persons will have the right to “self-perceived” gender identity. However change of gender identity in documents cannot be done without a certification by the District Magistrate after proof of a sex reassignment surgery is provided.]

The American Psychiatric Association (APA) defines gender dysphoria as “psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.” It states criteria to diagnose one with gender dysphoria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Activists in countries deemed more LGBTQ-friendly than the rest of the world consider the diagnostic criteria groundbreaking for transgender people. Clinicians in countries like Canada and the Netherlands claim that the criteria has allowed trans youth to safely access medically supervised gender affirmation surgeries, and that removing the criteria would do more harm than good. And what’s more— leading psychologists recommend gender-affirmative treatment (in medical terms and legal) anyway- and they have been for years. The APA even released a statement in 2013 asserting their support for trans rights.

While the APA’s definition of gender dysphoria may seem blanket and affirming, it is imperative to understand the nuance of the diagnosis and it’s intersections with the law.

For one, the criteria, like all others, does not come without its historicity and baggage. At the time of the release of the APA’s statement taking a position to back trans persons, they also introduced changes in the DSM to reflect a more informed vocabulary. Hence, they struck down ‘Gender Identity Disorder’ from the new DSM iteration released in 2017. This moved was interpreted by many to mean that trans people are no longer considered mentally ill solely on the grounds of our transness, similar to how homosexuality was struck down as a mental disorder in 1973.

However, this view is ill-informed, perhaps largely due to the APA’s vague and duplicitous manner of conduction. The diagnosis of ‘Gender Identity Disorder’ has only been renamed to ‘Gender Dysphoria’, and the criteria, in itself, still remains. Hence, it is better understood as a revision than a removal. Being trans is considered a mental illness in the DSM in any and every way that it was before.

Moreover, not only is the criteria stated problematic, but so is the outdated idea of trans lives it reflects. It specifies that there must be a “marked incongruence” between one’s expressed/experienced and chosen gender. What is meant by a “marked incongruence” here? Non-conforming gender expression? A new name? New pronouns? Does the DSM see masculine trans women as less trans? What must one do to prove one’s transness? How much incongruence is incongruent enough for the medical community to recognize us as valid? Will they ever realize the trans community will never hold its breath for their validation?

The criteria then states that there must be a “strong desire” to be treated as the other gender, be of the other gender, or have the sexual characteristics of the other gender to have gender dysphoria. This further highlights the issue in having a diagnosis for dysphoria. In a transphobic state, how would one reflect this “strong desire” to be their authentic selves? There is no lack of transphobic psychotherapists and counselors in the field of metal health. Every criteria demands some proof on behalf of the ailed, and queer and trans persons are in no social position privileged enough to provide this proof. Additionally, what is a “strong” desire? How strong is strong enough for the APA to believe our stories about ourselves? Will the APA ever realize we don’t need them to?

Perhaps it is psychological suffering that the APA needs to see as proof of our identities, and that brings us to the heart of the problem. Towards the end of the criteria, the DSM goes on to say, “…the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

That has always been key to the recognition of trans persons in society: our suffering. The image of the trans person must always be distressed, violated, begging on the roads, engaging in sex work as a last resort, pleading for justice, or just deeply miserable, obviously due to our own transness. Why must we be impaired in any manner of functioning to identify the way we do? Why do we have to act as if our identities bring us misery and not boundless joy?

The issue of trans misery is so vital because it is as much legislative in nature as it is psychological or philosophical. The Trans Act (2019) mandates that in order to identify as trans, one needs a psychologist’s certificate stating the diagnosis of gender dysphoria. Why do the judicial, legislative, executive, and medical communities want us to be miserable to be valid?

Furthermore, the idea that one must have to prove their dysphoria, their distress in order to gain access to gender-affirmative psychological treatment or surgery is absurd. While the benefits to trans youth in certain progressive countries is uplifting news, one must have the right to self-identify and access medical resources even if undiagnosed with gender dysphoria. The hurdles in finding a trans-affirmative therapist are self-explanatory. Transness need not be medicalized in order for trans persons to deserve medical relief; nobody goes through life changing bodily transitions as a side hobby. Lastly, not all trans persons experience dysphoria in the first place, and that does not make them any less trans or marginalized.

There are more issues surrounding the idea of the diagnosis. One is the inclusion of a ‘transvestic disorder’ in the DSM, that stigmatizes cross-dressing in individuals. This is a differential diagnosis offered to the diagnosis of gender dysphoria. Not only is it ridiculous in itself to medicalize someone’s clothing preferences and impose gendered expectations onto them, it makes it easier for counselors to dismiss trans persons as disordered cross-dressers.

Another is that trans persons will always be seen as mentally sick as long as elements of the trans experience are medicalized.

In addition, the DSM thoroughly fails to acknowledge the socio-political aspect of the issue. A large part of the experience of dysphoria comes due to misgendering, deadnaming, and presumption of gender identity in society. Dysphoria is rarely innate, if at all. One would never diagnose someone as poor. It is a “condition” caused by hierarchies in society, not due to any fault of their own. Then, why diagnose us with dysphoria and not the state with transphobia? After all, dysphoria does not arise magically out of our own cognitions.

Overall, the problems in the DSM are glaring, and nothing better could have been expected to be born out of the medical model. There is a need for easier access to medical and legal transition for trans people that also connects with mental healthcare resources. There is also a need for the APA to actually listen to those they diagnose, to treat us not as passive recipients of healthcare, but active participants and collaborators in shaping our own medical realities.

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Srishti Uppal is a nineteen-year-old poet and essayist from New Delhi. Their favourite writers include Alok V. Menon, Richard Silken, and Mary Oliver. Their work can be found in Marias at Sampaguitas, Human/Kind Journal, The Temz Review, among others.
Srishti Uppal

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